PONCE THERAPY CARE CENTER, THE

Nursing Home Inspector

1999 OLD MOULTRIE ROAD
SAINT AUGUSTINE, FL 32086
St Johns County
Phone: 904-824-3311
Provider Number: 105468
Last Inspection: 08/03/2017

About the Nursing Home

Number of Beds: 120
Number of Residents: 33
Beds Available: 87
Percent Occupancy: 28%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

11

Facility
8

County
15

FL
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

11

2017
9

2016
35

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

8/3/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 9/3/2017
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 9/3/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 9/3/2017
 

4/28/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 6/7/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 6/7/2016
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Isolated : Minimal 3 6/7/2016
 

1/23/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 3/16/2015
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 3/16/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 3/16/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 3/16/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 3/16/2015
 
Failed To: Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. Isolated : Minimal 3 3/16/2015
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 3/16/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 3/16/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 3/16/2015
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 3/16/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 3/16/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

2/2/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 3/2/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 3/2/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 3/2/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 3/2/2016
 

8/12/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Pattern : Minimal 4 9/22/2015
 

4/21/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Immediate 5 4/21/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Immediate 5 4/21/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Immediate 5 4/21/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg FL State Avg
Number of Residents 33 75.75 105.12
Registered Nurses 0.74 0.81 0.83
Licensed Practical / Vocational Nurses 1.48 1.08 0.92
Certified Nursing Assistants 3.34 3.07 2.79
Total Staff Hours 5.56 4.95 4.53

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% FL State Avg%
of high risk long-stay residents with pressure ulcers 8 5 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 97 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 95 93
of long-stay residents experiencing one or more falls with major injury 7 3 2
of long-stay residents who have depressive symptoms 0 3 1
of long-stay residents who lose too much weight 3 6 7
of long-stay residents who received an antianxiety or hypnotic medication 26 32 26
of long-stay residents who received an antipsychotic medication 11 15 15
of long-stay residents who self-report moderate to severe pain 2 4 3
of long-stay residents who were physically restrained 1 0 0
of long-stay residents whose ability to move independently worsened 26 18 17
of long-stay residents whose need for help with daily activities has increased 18 14 13
of long-stay residents with a catheter inserted and left in their bladder 4 1 1
of long-stay residents with a urinary tract infection 3 8 3
of low risk long-stay residents who lose control of their bowels or bladder 53 53 53
of short-stay residents assessed and appropriately given the pneumococcal vaccine 98 88 88
of short-stay residents who had an outpatient emergency department visit 17 14 10
of short-stay residents who made improvements in function 68 67 68
of short-stay residents who newly received an antipsychotic medication 0 2 2
of short-stay residents who self-report moderate to severe pain 5 9 10
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 96 87 85
of short-stay residents who were rehospitalized after a nursing home admission 28 21 24
of short-stay residents who were successfully discharged to the community 51 61 51
of short-stay residents with pressure ulcers that are new or worsened 4 0 0